ATI RN
ATI Capstone Comprehensive Assessment B
1. A client is about to undergo surgery and is unsure about the procedure despite signing the consent. What should the nurse do?
- A. Reassure the client and proceed with the surgery.
- B. Stop the surgery and consult with the surgeon.
- C. Proceed with the surgery but document the client's concerns.
- D. Postpone the surgery until further clarification is provided.
Correct answer: B
Rationale: When a client expresses doubts about a procedure after signing the consent form, it is crucial to stop the surgery and consult with the surgeon. This is important to ensure that the client's concerns are addressed, and there is a clear understanding of the procedure. Reassuring the client and proceeding with the surgery (choice A) may violate the client's autonomy and right to informed consent. Proceeding with the surgery but documenting the concerns (choice C) is not sufficient as the client's doubts should be resolved before proceeding. Postponing the surgery until further clarification is provided (choice D) may be necessary, but the immediate step should be to consult with the surgeon to address the client's concerns.
2. When administering IV fluids to a dehydrated patient, what is the nurse's priority assessment?
- A. Monitor the patient's electrolyte levels.
- B. Assess the patient's blood pressure regularly.
- C. Monitor the patient's heart rate every 4 hours.
- D. Check the patient's urine output hourly.
Correct answer: B
Rationale: The correct answer is to assess the patient's blood pressure regularly. Monitoring blood pressure is crucial when administering IV fluids to a dehydrated patient as it helps in evaluating the patient's fluid status. Changes in blood pressure can indicate the effectiveness of the fluid therapy, the patient's response to treatment, and the possibility of complications such as fluid overload or hypovolemia. Monitoring electrolyte levels (Choice A) is essential but not the priority when assessing a dehydrated patient receiving IV fluids. Heart rate (Choice C) should be monitored more frequently than every 4 hours in such a situation. Checking urine output (Choice D) is important but not as critical as assessing blood pressure in this scenario.
3. When caring for a patient with a nasogastric (NG) tube, what is the most appropriate intervention to prevent aspiration?
- A. Flush the NG tube with water before each feeding.
- B. Check the placement of the NG tube before each feeding.
- C. Elevate the head of the bed to 30-45 degrees.
- D. Provide the patient with oral care every 4 hours.
Correct answer: C
Rationale: Elevating the head of the bed to 30-45 degrees is the most appropriate intervention to prevent aspiration in a patient with an NG tube. This position helps reduce the risk of regurgitation and aspiration by promoting the proper flow of contents through the gastrointestinal tract and minimizing the chances of stomach contents entering the airway. Flushing the NG tube with water before each feeding may not directly prevent aspiration. Checking the placement of the NG tube is important but does not specifically address the prevention of aspiration. Providing oral care every 4 hours is essential for maintaining oral hygiene but is not directly related to preventing aspiration in a patient with an NG tube.
4. What is the primary purpose of turning and repositioning an immobile patient every 2 hours?
- A. To improve circulation and relieve pressure.
- B. To prevent contractures and muscle atrophy.
- C. To prevent skin breakdown and pressure ulcers.
- D. To improve respiratory function and prevent pneumonia.
Correct answer: C
Rationale: The primary purpose of turning and repositioning an immobile patient every 2 hours is to prevent skin breakdown and pressure ulcers. Prolonged immobility can lead to pressure ulcers, making this a crucial nursing intervention. Choice A is incorrect because while turning can help improve circulation and relieve pressure, the primary purpose is to prevent skin breakdown. Choice B is incorrect as preventing contractures and muscle atrophy is important but not the primary purpose of turning. Choice D is incorrect as improving respiratory function and preventing pneumonia are not directly related to turning and repositioning for skin integrity.
5. A nurse notices another nurse skipping hand hygiene. What is the appropriate course of action?
- A. Ignore the situation to maintain team harmony.
- B. Report the behavior to the supervisor.
- C. Discuss the issue with the nurse directly.
- D. Do nothing and continue with patient care.
Correct answer: B
Rationale: Correct hand hygiene is crucial for preventing the spread of infections and ensuring patient safety. When a nurse observes another healthcare worker skipping hand hygiene practices, it is essential to report this behavior to the supervisor. Reporting ensures that appropriate action is taken to address the issue and maintain a safe environment for patients. Ignoring the situation (Choice A) may compromise patient safety. Discussing the issue directly with the nurse (Choice C) may not always be effective in ensuring compliance. Doing nothing and continuing with patient care (Choice D) disregards the importance of infection control protocols.
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